UNRWA health programme – Department of Health 2010 Annual Report – Executive Summary

THE ANNUAL REPORT OF THE

DEPARTMENT OF HEALTH

2010

Executive summary

As the main comprehensive primary health care provider for Palestine refugees in the Near East, UNRWA has been the largest humanitarian operation in the region for 61 years. The Mandate of UNRWA on health is to protect and promote the health status of Palestine refugees within the Agency's five areas of operation (Jordan, Lebanon, Syria, the Gaza Strip and the West Bank) aiming for them to achieve the highest attainable level of health as indicated in the first Human Development Goal, A Long and Healthy Life, of the UNRWA Medium Term Strategy 2010-2015.

UNRWA currently runs 137 Primary Health Care (PHC) Centres and one hospital. In 2010, UNRWA medical officers in the PHC centres provided almost 10.4 million consultations. These were complemented by about 700,000 dental consultations and almost 260,000 dental screening sessions. About 86,000 people were assisted by the programme to cover hospital care costs, either in contracted secondary/tertiary care facilities or in the UNRWA hospital in Qalqilia (West Bank). By promoting continuative, comprehensive, health care from preconception to old age, focussing on primary health care and prevention, it has reached recognized results in improving the health conditions of refugees.

However, the challenges that UNRWA health services lace are paramount. The demand for health care is continuously increasing. The refugee populations increased from 4.8 million in 2009 to 5 million In 2010. The number of medical consultations increased from 10.36 million in 2009 to 10.42 million in 2010 and PHC centres remain extremely busy (101 consultations per physician per day). Non-communicable disease, or life-style illness, becomes predominant, which requires complicated, lifelong care of patients. Containing increasing hospital payment becomes difficult in the fields. At the same time, UNRWA health expenditure has not shown any actual increase as health expenditure per-registered refugee remains at USD 19.8 since 2008.

UNRWA health services started responding to these challenges. In 2010, a number of activities took place to respond and start implementing the recommendations of its on-going health care reform. This report provides a comprehensive and technical overview of the achievements of the Health Programme throughout 2010 structured according to the life cycle approach to health care that is promoted by the Agency. Specific chapters are dedicated to cross-cutting activities aimed at addressing the social determinants of health and delivering health to the victims of conflict.

The final chapter of this report is dedicated to the Programme Management stream which outlines the accountability and governance mechanisms adopted in 2010 in order to provide health care to Palestine refugees as well as the advocacy, monitoring, evaluation and operational research initiatives that have taken place in the reporting period. This executive summary reflects the chapter subdivision adopted in this report.

THE DEMOGRAPHIC PROFILE OF PALESTINE REFUGEES TODAY

The number of registered refugees showed continued increase in 2010: from 4,766,670 in 2009 to 4,966,664. Almost two millions of these refugees resided in the occupied Palestinian Territories (oPt) in the Gaza Strip and in the West Bank. The remaining were spread over three host countries: Lebanon, Syria and Jordan. Approximately 29% live in refugee camps, the others residing in un-official camps or in towns, and villages with host country communities. Across UNRWA’s area of operation almost 33.2% of refugees are children below 18 years of age. The UNRWA calculated 2009 dependency ratio, measured as the proportion of the population below 15 and above 65 years of age, was over 80% in the Gaza Strip. This implies that the economic burden on family units is particularly high, even not taking into account the contextually high unemployment rates and worsening poverty levels.

PRECONCEPTION CARE

The comprehensive preconception care introduced in 2009 was scaled up in 2010 by consolidating services for couples planning a pregnancy whilst continuing its long standing activity in family planning. About 24000 new couples were enrolled in the family planning programme during 2010, and the total number of continuing users of modern contraceptive methods agency wide increased from 134,729 in 2009 to 139,965 in 2010, a 3.7% Increase.

PERI-NATAL CARE

UNRWA continues to provide perinatal care at the PHC centres to sustain the gains in the health status of mothers and children and further reduce infant, child and maternal morbidity and mortality. Key progress in 2010 were the increased use of health information systems and e-health, the full implementation of the Maternal and Child Health booklet in all Fields and improvements in capacity building. Antenatal care was provided to 101,832 pregnant women, who accounted for 69.0% of all expected pregnancies among the registered refugee population. Hospital delivery increased from 95.8% in 2009 to 96.8% in 2010. Post-natal care was provided to 92,754 women covering 92.6% of expected deliveries.

INFANT AND CHILD HEALTH

Infant and child health focuses on providing paediatric preventive and curative services as well as school health services.

A total of 286,343 infants and children below 36 months of age (compared to 282,259 in 2009) received preventive care at UNRWA primary health care facilities Including a thorough medical examination, growth monitoring, immunization against vaccine-preventable diseases and During the school year 200912010, a total of 50,033 new entrants were registered in UNRWA schools of whom 25,016 girls and 25,017 boys. They all benefited from the comprehensive school health services offered by the Agency including medical examination, immunization, screening for vision and hearing impairment, oral health consultation, vitamin A supplementation, de-worming, health education and promotion activities.

ADOLESCENT AND ADULT HEALTH

In the oPt over 15,000 refugees benefited from individual mental health counselling sessions, almost 30,000 from group counselling and over 4,000 received home visits from UNRWA mental health staff.

In order to meet the demand for physical rehabilitation in the oPt as a result of violence, UNRWA operates ten physiotherapy units in Gaza and six units in West Bank, providing a wide range of physiotherapy and rehabilitation services. In 2010, over 14,000 patients were treated in the oPt.

Qaiqilia hospital had an average daily bed occupancy rate In 2010 of 61.0% and over 6,000 people were admitted.

ACTIVE AGEING

Non-communicable Diseases INCD), or life-style illnesses, become a predominant health problem for Palestine refugees. The reduction of communicable disease Incidence combined with modifications in life style and longevity have led to this change in the Palestine refugees morbidity profile with the emergence of non-communicable diseases such as cardiovascular diseases, diabetes mellitus and cancer. The number of people with NCD assisted increased steadily since 2000 reaching 199,412 in 2010. Although proportional mortality among patients affected by diabetes and hypertension followed by UNRWA clinics remained stationary at 1.9% in 2010, the increase confirms the epidemiological trend that is seeing an increasing importance of Non-communicable diseases as causes of morbidity and mortality among Palestine refugees.

ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH

Addressing the social determinants of health such as nutrition and environmental health has gone a long way to Improving the health status of Palestine refugees In the past 61 years. Delivery of essential sanitation and clean water services was maintained in 2010 notwithstanding difficulties faced in particular due to the closure regime and conflict in the oPt. Almost all Palestine refugees in camps today have access to clean water and sanitation services, while the Integrated Community Based Initiative Programme is striving to improve living conditions and limit health inequalities in camps.

In the decade since the start of the Al Aqsa Intifada, the West Bank and the Gaza Strip have been in the grip of a protracted humanitarian crisis. In Gaza, despite a partial easing of the blockade announced in June 2010, on-going restrictions severely limit economic recovery, leaving a large majority of the population dependent on UNRWA for food aid and other basic services. In the West Bank, the separation Barrier and the hundreds of other physical obstacles and checkpoints continue to have a major impact on the population and on UNRWA’s ability to deliver humanitarian services. In Lebanon, three years after the conflict of 2007, the reconstruction of Nahr el-Bared Camp (NBC), not only for health but in general, is still being stagnant. UNRWA is acting to mitigate the impact of political instability and conflict on the health of refugees through a combination of interventions that include outreach medical services, institution of provisional health centres, increased coverage of the costs of hospitalization and Implementation of programmes focusing on mental health and physical rehabilitation.

PROGRAMME MANAGEMENT

The Health Programmes expenditure in 2010 was USD 98.6 million. Around 3,654 staff members work for the Health Department across the five Fields of operation, including the staff employed in Qaiqilia hospital. Staff to population ratio (registered population) in 2010 was 9.5! 100,000 for physicians and 22.3! 100,000 for nurses. The first steps in implementing the framework of the health reform began in 2010 based on the planning conducted in 2009 as a result of the monitoring and evaluation carried out in 2008. Health Department at headquarters and In fields started the restructure to address health reform, Advocacy, among the scientific medical community, was fostered through the publication in scientific international journals and strong ties with international partners were maintained and expanded. These include other United Nations Organizations, Ministries of Health (M0H) In the host countries as well as Universities and Academic Institutions.

THE UNRWA HEALTH PROGRAMME: IMPLEMENTING A HEALTH CARE REFORM

In this introductory overview of the health status of the population served by UNRWA in 2010, we will first of all describe the UNRWA Health Programme as a whole and the health care reform process in particular through the eye of the West Bank Field experience. Then UNRWA beneficiaries in 2010 will be described in terms of their socio-economic profile and of issues of access inequity to health and heath care services in each of the host countries where they reside. Conversely to previous editions of the annual report of the Department of Health, this year this chapter will also present in a fact sheet format, the key issues faced and the main achievements reached in 2010 by the Health Programme as a whole and by each Field of operations.

THE HEALTH PROGRAMME TODAY

As the main comprehensive primary health care provider for Palestinian refugees in the Middle East, UNRWA has been the largest humanitarian operation in the region for over 60 years. By promoting continuative, comprehensive, health care from preconception to old age, focussing on primary health care and prevention, it has reached recognized results in improving the health conditions of refugees [1, 2].

The UNRWA Health Programme is undertaking a programmatic shift as part of a major health reform that aims at increasing quality, efficiency and effectiveness of activities in light of the chronic disparity between the refugee needs and the financial resources available. This programmatic shift started in 2009 with the life cycle approach to health.

Refugees are assisted from preconception to active ageing through preventive and curative health services that include post-natal follow-up of infants (growth monitoring, medical check-ups and vaccinations), outpatient consultations, family planning, ante-natal care of pregnant women, oral health, in addition to secondary prevention and management of diabetes and hypertention.  Control of communicable diseases is achieved in part through high vaccination coverage and in part by the early detection and control of outbreaks through a health centre based epidemiological surveillance system. The environmental health programme controls the quality of drinking water, provides sanitation and carries out vector and rodent control in refugee camps thus reducing the risk of epidemics. In 2010, the Agency managed a network of 137 clinics, located both inside and outside the refugee camps, serviced by 3,654 health care workers, including 470 doctors who conducted 10.4 million medical consultations.

In 2010, the Health Programme has started to implement the recommendations of an in-depth evaluation of its activities performed in 2009 with the aim to transform UNRWA’s health services into a comprehensive, horizontal, population- focused Primary Health System, to obtain – but not necessarily provide – the best possible Hospital Care at a cost affordable for most beneficiaries, to update its structure and procedures to the new needs, and to become an active actor in all venues where the health of the Palestine refugees is discussed. In order to achieve this, the reform process involves not only health services directly provided by the Agency, but also redefines Secondary and Tertiary Care, usually contracted to other providers, the systemic components of the health program, including management, organization, and the structure of the Health Department and how the UNRWA Health Program interacts with other partners.

HEALTH SECTOR REFORM:  THE WEST BANK FIELD OFFICE EXPERIENCE

The UNRWA Health Department is implementing strategic reforms in management, capacity strengthening, and partnerships to improve the quality of its service delivery.

DECENTRALIZATION OF HEALTH SYSTEM MANAGEMENT

Decision-making in the health sector has traditionally been centralized and top-down, resulting in a disconnection between the unique needs of patients at the community level, and service delivery.

In order to improve the quality of its health services, UNRWA has been expanding management responsibilities to the area and health centre levels, allowing health centres to better meet their communities’ needs. Last year, six health centres in the northern, central, and southern regions of the West Bank began assuming greater management and decision-making responsibilities. Senior staff was trained in management and decision-making, developed work plans, and were allocated funds for activities. As a result, health centres demonstrated greater empowerment, ownership, and innovation in providing high-quality health services. With a budget to manage and decision making authority, health centres engaged community organizations and leaders in health promotion activities, Communities also increased their involvement in health, donating equipment, space, and materials for the health centres and their programmes.

A STRATEGIC APPROACH TO CAPACITY BUILDING

The Health Department adopted a strategic approach to capacity building, based on the guiding principle that every stall member receives the opportunity for professional development. In 2010, a performance improvement officer and a committee comprised of division heads, were assigned to oversee the capacity building needs of health stall. Through training workshops, short-term technical assistance, and strategic partnerships with international education institutions, health and non-health stall was given equal opportunities to strengthen and broaden their capacities.

STRATEGIC PARTNERSHIPS AND COOPERATION

The Health Department has been an active participant in policy-making, planning, and development of the Palestinian national health sector. It enjoys a strong partnership with the Ministry of Health, working jointly to harmonize and standardize protocols and standards (e.g. child records), and to transfer technologies such as verbal autopsy to monitor maternal mortality. The Health Department also developed strategic partnerships with NGO health service providers, training institutions, local and international and universities, other UN agencies, and international donors and NGOs (see box), For example, and of particular significance, Is the mobile mammography and diabetic services being delivered in cooperation with the Augusta Victoria Hospital in East Jerusalem.

The Health Department has also forged strong partnerships with its communities, establishing Health Committees comprised of health stall, community members, and local committees, in every refugee camp. This has resulted in a full buy-in, participation, and investment by communities in health. For example, Askar and Dheisheh refugee camps donated building space for new UNRWA clinics. Through this community donation. refugees living in these camps have greater access to health services.

THE WAY FORWARD

The health department will continue implementing these Innovations related to health management reform, capacity strengthening and quality Improvement. The six health centres will continue to strengthen their management capacities, through capacity building and the development of management information systems. Next year, six additional health centres will participate In this initiative, with training and capacity building support provided by a Palestinian organizational development consulting firm.